Stomach

Question 1

A patient is here to see you because of abdominal pain with indigestion and is always satiated after a few bites. You note a 10 pound weight loss since you last saw them, and they’re not trying to lose weight. What diagnosis are you thinking of?

Answer 1

Stomach cancer

Question 2

What is the most common type of stomach cancer?

Answer 2

adenocarcinoma

Question 3

What might you look for on PE if you suspect stomach cancer?

Answer 3

palpable mass & lymphadenopathy! (supraclavicular, umbilical, and axillary)

Question 4

: How would you confirm diagnosis of stomach cancer?

Answer 4

Endoscopy + biopsy

Question 5

If a patient has nausea & vomiting and feelings of excessive fullness after small meals, you should rule out cancer, but what other diagnosis might you be thinking of?

Answer 5

Gastroparesis

Question 6

How do you treat gastroparesis?

Answer 6

Prokinetic medications to help speed movement through the stomach.

Question 7

What diagnosis do you think of with babies when they have non-bilious projectile vomiting after feeding?

Answer 7

Pyloric stenosis

Question 8

What do you look for on PE with pyloric stenosis?

Answer 8

Olive sign – palpable mass over the epigastric region. Also look for signs of dehydration/jaundice

Question 9

How do you confirm diagnosis of pyloric stenosis?

Answer 9

Abdominal ultrasound – shows hypertrophy of the pyloric sphincter

Question 10

How do you treat a baby with pyloric stenosis?

Answer 10

Replace fluids/electrolytes. Pyloromyotomy

Question 11

Your patient presents with epigastric pain that is burning and almost hunger-like. What diagnosis are you thinking?

Answer 11

Peptic ulcer disease

Question 12

What is occurring in peptic ulcer disease?

Answer 12

A break in the gastric or duodenal mucosa

Question 13

What are some causes of PUD?

Answer 13

NSAIDS, H pylori, smoking

Question 14

When might your patients states they feel better with PUD?

Answer 14

With eating or antacids

Question 15

When might your patient states they feel the worst with PUD?

Answer 15

Nocturnal awakening; may have back pain → indicating penetrating or perforating

Question 16

What tests can you do when you suspect PUD?

Answer 16

Hbg/Hct for anemia, Endoscopy with biopsy to test for urease, H pylori testing = fecal antigen & C-urea breath test

Question 17

What is the major different between gastric & duodenal ulcers?

Answer 17

Gastric ulcers can be malignant

Question 18

What are the two main categories of treating PUD?

Answer 18

If H pylori present or not

Question 19

If H pylori is not present, how do you treat PUD?

Answer 19

PPI 1-2x daily; stop any NSAID use!

Question 20

If H pylori is present, how do you treat PUD?

Answer 20

Quadruple therapy = PPI 2x/day; Bismuth 2-4x/day; Tetracycline; and Metronidazole x 10-14 days

Question 21

How long does it take a duodenal vs gastric ulcer to heal?

Answer 21

Duodenal = 4 weeks
Gastric = 8 weeks

Question 22

Once our patient has completed treatment for PUD, what must we do?

Answer 22

Repeat H pylori testing to confirm eradication

Question 23

Say a patient has just stopped their PPI yesterday and we want to test to confirm H pylori eradication, is this okay?

Answer 23

No, need to be off PPI for 2 weeks

Question 24

What happens if H pylori is NOT eradicated?

Answer 24

If 1cm = continue PPI for 2-6 weeks

Question 25

What’s the likelihood for ulcer recurrence?

Answer 25

Usually very low, if H pylori is confirmed eradicated & NSIAD use has stopped. And smoking has stopped!

Question 26

What if our patient completed treatment and they have ongoing symptoms or multiple recurrences?

Answer 26

Warrants a repeat endoscopy & biopsy for malignancy

Question 27

What is the second line treatment for PUD?

Answer 27

H2 receptor antagonist (zantac or pepsid)

Question 28

If we have a high risk patient for PUD, what would we use to treat them prophylactically?

Answer 28

PPI

Question 29

If the patient you are worried about PUD has a low Hgb/Hct, an elevated BUN, and changes to their PTT, what are you thinking?

Answer 29

Bleeding ulcer

Question 30

How do you treat a bleeding ulcer?

Answer 30

Endoscopy, can be used to stop the bleeding too. IV PPI. H pylori eradication if present.

Question 31

What does long term use of NSAIDS impair?

Answer 31

Impairs gastric mucus/HCO3 secretion (AKA decreases our protective mechanisms)

Question 32

What type of patient are we most concerned about developing gastritis?

Answer 32

Alcohol use, NSAID use, and stress (in ICU)

Question 33

How do you confirm diagnosis of gastritis?

Answer 33

Endoscopy

Question 34

How can gastritis present?

Answer 34

Asymptomatic – N/V with dyspepsia – UGI with hematemesis or coffee ground emesis

Question 35

What type of patients in the ICU are we most concerned about developing gastritis?

Answer 35

Respiratory failure/mechanical ventilation; coagulation problems, or CNS injury

Question 36

What prophylactic treatment do we have for these ICU patients to prevent gastritis?

Answer 36

PPI – oral/NG

Question 37

What form of gastritis is most unrecognized due to its lack of SxS?

Answer 37

NSAID Gastritis

Question 38

How do we treat NSAID gastritis?

Answer 38

Stop NSAIDS and PPI for 2-4 weeks

Question 39

What is the tumor called that causes a hypersecretory state of gastrin?

Answer 39

Zollinger-Ellison syndrome

Question 40

What may go along with zollinger-ellison syndrome due to the excess acid secretion?

Answer 40

Duodenal ulcers

Question 41

How do we confirm Zollinger-Ellison syndrome?

Answer 41

Increased serum gastrin; pH

Question 42

How do you treat zollinger-ellison syndrome?

Answer 42

If isolated tumor = PPI + resection

If metastasis = PPI in high dose